Radiation Oncology Roundtable

Despite the fact that about a third of all cancer patients receive radiation therapy in some form, this invisible and painless procedure remains the least understood common cancer treatment. Providence Cancer Center News recently sat down with Christine Cha, M.D., Jeannie Louie, M.D., and Richard Rodriguez to find out why radiation matters today.

Q: Radiation therapy is often the last treatment a patient will undergo for cancer. A patient might say, "I've had the surgery, I've had the chemotherapy, my doctor now says I have to have radiation therapy. Do I have to?"

LOUIE: "Why do I need radiation therapy?"

Q: And they think it's going to be awful.

LOUIE: Right. They say, "I've heard so much about radiation; it burns."

Q: So how do you respond to that?

LOUIE: Radiation is one aspect of cancer treatment. The surgery takes care of the local area; the chemotherapy takes care of systemic disease. The radiation is an extension of the surgery: It gets to where the surgery can't go and extends the surgery without leaving surgical defects. So in a case like breast cancer, it takes care of the microscopic disease left behind, where further surgery would be quite deforming and wouldn't be the best for the patient at that point. And the techniques of radiation have changed so much in the last 20 years that the side effects that you read about when you do Internet searches don't exist today, most of the time.

CHA: You know a lot of doctors don't know very much about radiation, and in fact until fairly recently a lot of people who ended up working in radiation treatment - how they found out about the field - is, well, they had a patient on the floor that they were taking care of, and the patient kept going downstairs to a place called "radiation" -

LOUIE: - and the patient comes back with tattoos on him.

CHA: Right, and so the resident would go down out of curiosity and go, "Oh, what is this place?" But there were a few people, about ten or fifteen years ago, who were really active proponents of radiation treatment, teaching people "what is radiation" - really sort of showing the community (as well as the medical doctors) that, hey, radiation is something that's not out of the dark ages; it plays a really important role for cancer treatment, and it helps a lot of people.

Q: So how does it make you feel when you hear a patient or somebody else refer to it as "nuking" or "zapping" or...

[Laughter]

LOUIE: Well, "burn" is a four-letter word in our department. But, yes, when someone says it, you just try to explain to them what radiation is, and you kind of straighten them out a bit.

CHA: I think there's a big role for education. People know what surgery is, people kind of have an idea of chemotherapy from television shows and movies, but not a lot of people understand about radiation. The things they've heard about radiation are from the Cold War, Hiroshima, Nagasaki, Three Mile Island, and so there's a lot of nervousness about that, but oftentimes we can educate people. One of the wonderful things about working at Providence is that we have leading-edge technology, and we have great staff, and we've been able to create a very caring, very high-quality environment -- and that's what we want people to think of when they hear about radiation oncology

LOUIE: Yes, I agree with that.

RODRIGUEZ: The follow-up on that is the number of patients who tell us about how they will miss us after the completion of their treatment, because we become a big part of their everyday lives for several weeks, and that's why we're supplied with lots of cookies and cakes. [Laughter] That's just one way that they show it wasn't what they expected.

Q: You've all seen the articles that have been coming out this year that suggest that a lot of the benefits of radiation therapy could be extended to special groups of prostate-cancer, breast-cancer, and lung-cancer patients - even to patients for whom radiation therapy was once considered dangerous. Did that news surprise you? How does that match up with your current practices?

CHA: Well, you know one of the exciting things about being in cancer treatment is that it is constantly evolving with the technology, with the research, as well with the findings from the lab; so I'm not that surprised. For example, we're getting the latest generation of linear accelerators for the new cancer center. Some of these studies that were done that said radiation is not helpful for some patients - that was on older technology with older techniques. People really have to be aware that in radiation oncology technology is critical, and the techniques and methods that were used…

LOUIE: ...ten years ago...

CHA: ... even five or ten years ago are considered out of date. And so even our medical oncologist colleagues or surgical colleagues who deal with cancer patients a lot, they don't have the same grasp of how far we've come, and so radiation therapy is always something that it is debated and discussed.

Q: So is the way in which the technology has changed to offer better outcomes is that it has become more precise?

ALL: Exactly

Q: And what are some examples of that?

CHA: One of the more exciting developments is the use of radiolabeled antibodies - putting a radiation isotope on a molecule and sending that through the blood system to target certain lymphomas and leukemias.

Q: Are we doing that?

CHA: It is being done at Providence, and it's usually being done through nuclear medicine, although sometimes we assist if their schedule permits it. It's very well tolerated. It does require a lot of coordination, but it can be very, very effective for some patients.

One of the things that we're going to have in 2008 in the new cancer center is Image Guided Radiation Therapy (IGRT) on all new machines - three of them. The technology is so new that even major cancer centers like MD Anderson and Sloan Kettering are still doing the research protocol to figure out the best way to utilize this technology. Basically, it's building on taking not just images at the beginning of treatment or at the end of treatment, but actually taking images every single day, five days a week for several weeks-for better accuracy.

LOUIE: Historically, when radiation first started, it was just a beam. It was like a flashlight beam that you just kind of aimed toward the patient. Now, with image guided radiation therapy (IGRT), we've gotten to the point where you outline the tumor depending on how the patient is positioned on that particular day of treatment, and the tumor position on that particular day in relationship to other anatomy. The challenge is to focus just on that tumor without hitting a lot of normal tissue.

CHA: Right, so if the patient is moving around or, let's say, the patient has lost a lot of weight, or if they had a really big tumor when they started out, but that's been shrinking a lot, IGRT is going to actually account for that. And that makes a big difference.

LOUIE: IGRT is the next step.

CHA: So even when I was in training ten years ago at Sloan Kettering, which is an extremely well-known cancer facility in New York City, the state of the art at that time was just to do a chest x-ray and then sort of plan your radiation blocks from that chest x-ray. That was the best technology we had. Now what we're doing is Computed Tomography (CT), which is great, because we actually get a 3-D reconstruction of where the tumor is and where the heart is - and with the lungs we actually measure the volume. IGRT is going to take that one step further and some people are even looking with lung cancer into gating with your respiration with how the tumor moves, because obviously your lungs are flexible and the tumor moves up and down as you breathe. When you're aiming the beam at a certain area, you need to have a certain margin to make sure that the tumor doesn't move out of range when the patient is treated. Potentially with IGRT, we will be able to make tiny adjustments to the beam to account for the patient's breathing.

LOUIE: So the big advantage is that where we used to treat an extra inch beyond the tumor because of breathing, today we can treat a margin of just a half an inch beyond the tumor and move with the tumor.

Q: Do you have to get more sophisticated in your positioning because the equipment has become so precise?

RODRIGUEZ: Well, yes. Like Dr. Louie said, it is a challenge, and there are different ways that the departments will handle it. One of the things that we currently use is ultrasound for localization of prostate cancers. So, what we're doing then is adjusting the beams in real time for those daily differences.

LOUIE: So quality assurance has to become even more important. When we're treating the whole breast, the patient will typically ask, "Why do you take films once a week?" Well, they're quality assurance films. We're just checking to make sure that there has not been human error in any of the set-ups.

CHA: But we also adjust. I mean, some patients, they may have been really tense when they started treatment, and that's one set up, and then they relax and you have to adjust for the fact that their body has shifted and their set up has changed.

LOUIE: That's one thing that the physicians will look at - they ultimately make that decision - but at the same time we're also going to increase the staff's knowledge because they are the ones who are making those changes on a daily basis.

Q: So it sounds as if as your staff becomes even more highly specialized and more highly trained, the education component become even more important, especially when you're working with primary care physicians.

CHA: It definitely does, and as a group we are all required to keep up on the latest data, attend journal clubs and tumor boards. Each member in our group is set up so that we are required to go to national meetings at least twice a year, and oftentimes we do more than that just for our own edification.

Q: How do you work with a cancer specialist or primary care physician to come up with treatment options for a patient given the fact that you may be more abreast of the innovations in radiation cancer treatment than he or she is - because how can you keep up with this stuff?

CHA: Definitely. I don't make recommendations for chemotherapy; I defer that to the medical oncologist, and likewise they defer the radiation aspect to us. Certainly there's a lot of healthy discussion, and one of the nice things is that we have very good relationships. Definitely everyone here has really tried to work in the patient's best interests and work as a team. The whole purpose of the tumor boards is that patients' cases are discussed amongst a group, so it's not just one radiation oncologist or one medical oncologist making the decision. It's a whole group of people. The other thing that I think we do on a casual basis is just keep in good contact and maintain good relationships with not only the medical oncologists and surgeons who are involved, but also the primary care physicians, because a lot of times there are patients we're going to help, and we're going to be very invested in their care, but we're not necessarily going to cure them. And so, coordination with primary care doctors is very key, because end-of-life care is very important as well.

LOUIE: I agree. The multi-disciplinary tumor boards are very important because that's where you can sit down with the patient's other physicians and definitely see the same films together, review the pathology together, and so everybody's on the same page. So there's not just one little cowboy riding off and doing something and nobody else knows what that person is doing.

Q: Dr. Louie, you described radiation therapy as an extension of surgery.

LOUIE: It's an extension in that, let's say you take a tumor out and you know that there might be microscopic cells beyond that tumor, even though the margin of resection was negative. That's what radiation does: It takes care of the microscopic cells so it extends the surgery in a sense.

Q: Is that typically the role of radiation therapy?

LOUIE: As a primary treatment, yes. In some cancers it's an adjuvant treatment to surgery, and in some cases it's the primary treatment.

CHA: I think that there's often a bias when treating younger patients to choose the most aggressive treatment, but, as I said, these treatments evolve over time. Clearly surgery was the earliest form of treatment. You know, the ancient Egyptians were doing surgery. So conceptually it's easier for patients as well as physicians to understand surgery - to feel, well take it out…

LOUIE: ..take it out!…

CHA: ...it makes sense. Why leave it in there? So that's been why I think there's been a slight bias against doing radiation treatment. And so why this study is really important is because I think that, with more widespread education about radiation, people have been more willing to consider radiation treatment, particularly if you're older. What recent studies are saying is that it's not just for older people - this is beneficial for younger people, too - the people that we automatically want to jump and say, okay let's just take it out, they're going to live a long time, let's be as aggressive as possible.

Q: When it can be a primary therapy or an alternative to surgery, what are the advantages that radiation therapy may present a patient?

LOUIE: Besides not having to go through the incision, the bleeding, and the infection side effects? The big difference is that it's not invasive.

CHA: Or another way you can think of it is in terms of side effects. We talk about chemotherapy affecting many different areas of the body because it travels through the blood system. With radiation treatment, it's very much where we point the radiation treatment - that's where the side effects are.

Q: Is radiation going to take more of a treatment role in the future because of its noninvasive qualities?

CHA: I think that clearly radiation is a very key component. Take, for example, the treatment of breast cancer. The standard surgical treatment for breast cancer used to be a radical mastectomy, where they take out the pectoral muscles and everything around the breast, and then they got down to a modified radical mastectomy where they take off the breast tissue, but leave the chest muscles, but they still do a full axillary node dissection. Then people started saying in the 1970s, Can we just take out the lump, check the axillary nodes and then do radiation for the rest of the breast? and people said, Oh, okay, we could probably do that. Then about 10 years ago, people said: Well, do we need to take all the axillary nodes? Maybe we could just take a couple and if those aren't involved we could skip that. In the last 3-5 years in radiation therapy for breast cancer, we're asking, Do we need to irradiate the whole breast? Maybe we just need to do part of the breast

LOUIE: So with cancer treatment, once we've obtained good control of the cancer, then we start thinking, well how can we minimize treatment, how can we minimize side effects? Another typical case is Hodgkins. For Hodgkins Disease you used to do a biopsy and the patient would undergo a spleenectomy and have all these other lymph nodes taken out, and then they would get radiation to practically the whole body, and then possibly even chemotherapy. Now we've moved away from that. Surgery is now just a biopsy, radiation is limited to just a certain area, and then you combine that with chemotherapy.

CHA: And the dose of radiation is half of what it used to be.

LOUIE: Because we can still control the cancer without the side effects. So, will radiation ever replace other therapies? I think it really works in conjunction with everything else.

Q: So it's really the coordination of these three components - surgery, chemotherapy and radiation - that allows you to preserve more tissue?

LOUIE: Right. It's definitely a team effort.

CHA: It's definitely a team effort, and also we may be trumped completely by genetics.

[Laughter]

LOUIE: Exactly.

CHA: You know, the day may not be far off that when you're born, you'll have a blood sample taken that's sent off and they'll say, "Well, you're at risk for prostate cancer, so you should probably get your prostate screened, and you're not at risk for Hodgkin's disease, so we're not going to worry about that, and, oh, there might be a modified risk for lung cancer, so you'd better not smoke!"

LOUIE: And beyond that, we may be able to fix that gene problem with a certain drug so you won't get prostate cancer.

CHA: Cancer treatment could change dramatically in the next 10 to 25 years.

Q: So is that what it's like to work in radiation oncology? You look back 10 years, and things were totally different, and you know that when you look ahead it's going to be totally different?

LOUIE: It's constantly changing.

CHA: Well, by the same token, I think five years ago I went to a meeting with one of my partners - she's a few years older than me -- and there was a lecture given by a very famous professor from Harvard talking about new research on a cure for cancer. And my partner was convinced that we all needed to start opening body spas because we're all going to be out of job in five years. [Laughter] So, five years later, that hasn't quite happened. We're still around. But it is changing, definitely. Our job is to keep up with those changes to provide the best treatment opportunities to our patients.

Providence Health & Services in Oregon is a not-for-profit Catholic network of hospitals, care centers, health plans, physicians, clinics, home health care and affiliated services guided by a Mission of caring that the Sisters of Providence began in the West nearly 160 years ago.